Bladder Health Questionnaire
Please bring this form with you on the day of your appointment.
Name______________________________________________________ Date: ____________________
Last menstrual period: ____________ Allergies: _____________________________________________
Please write in your own words, the nature of your current problem._____________________________
____________________________________________________________________________________
When did your bladder problems begin?
How often do you urinate during the day/evening?
How often do you get up at night to urinate?
_____________________
_____________________
_____________________
How would you rate the effect of your leakage on your lifestyle?
• Little or no impact
_____
• Somewhat bothersome
_____
• Severely interferes with my lifestyle
_____
When urinating, do you feel you have completely emptied your bladder?
When urinating, can you stop your stream?
Can you postpone emptying your bladder easily?
Do you experience pain when your bladder is full?
Do you have pain when emptying your bladder?
Do you usually have a strong sense of urgency to urinate?
Do you ever wet your bed at night?
Do you notice dribbling of urine after emptying your bladder?
Do you lose urine when:
You are lying down or asleep?
You sneeze, cough, jump, run, or laugh?
You get up from a sitting position?
You hear, see or feel running water?
You can’t get to the bathroom on time?
You don’t even know it?
Do you wear protection for urinary leakage?
If yes, do you use:
Panty liners
Shield-type pads
Briefs
Underwear
If yes, how many do you wear per day? _______________
Do you have difficulty starting your urine stream?
Yes
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No
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Sometimes
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Misa T. Belazi, MD ▪ David S. Hulbert, MD, FACOG ▪ Paul L. Schell, MD, FACOG ▪ Francine M. Siegel, MD, FACOG ▪ Michael T. Snyder, MD. FACOG
Michael I. Zalkin, MD ▪ Dolores C. Fee, RN, APN – C ▪ Lori M. Grisko, RN, APN – C ▪ Trya R. Jones, RN, APN – C ▪ Jennifer J. Shiroff, RN, APN – C
2110 Ark Rd. Ste. 216
Mount Laurel, NJ 08054
856.778.2060
1000 Salem Rd., Ste. B
Willingboro, NJ 08046
609.871.2060
8008 Rt. 130 N, Ste. 320
Delran, NJ 08075
856.764.0002
advocareBCOBGYN.com
45B Homestead Dr.
Columbus, NJ 08022
609.324.7424
(12/11)
How do you start your urine stream?
Easy
Push/strain
Wait less than 1 minute
Wait more than one minute
_____
_____
_____
_____
Have you ever had a tube placed in your bladder because you were
unable to empty you bladder?
Have you ever had your urethra dilated or stretched?
Have you ever passed blood in your urine?
Have you ever had a kidney or bladder infection?
Have you been treated for three or more urinary tract infections?
Have you had an infection within the last 6 months?
Do you notice a bulge or anything protruding from your vagina?
Do you leak gas or stool?
Are you constipated?
Do you have to push on your vagina to have a bowel movement?
Yes
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No
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Sometimes
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What treatments for your bladder problems have you tried in the past?
Kegel exercises
_____
Pessary insertion
_____
Fluid/diet changes
_____
Medications
_____
List them ________________________________________________________
Surgery (list below)
_____
Collagen injections
_____
List all the medications you have been taking over the last 6 months:
____________________________________________________________________________________
____________________________________________________________________________________
Do you take aspirin?
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If yes, how often?
___________
How many pregnancies have you had? ____
Vaginal deliveries? ___ C-section deliveries? ___ Miscarriages? ___
How many caffeinated beverages do you drink daily?
____
How many cigarettes do you smoke each day?
____
When was the last time you had sexual intercourse?
____
Do you have pain during intercourse?
____
List all the surgeries you have had and the dates of each:
____________________________________________________________________________________
Do you have the following?:
____ Heart problems/Murmurs
____ Multiple sclerosis
____ Diabetes
____ High blood pressure
____ Parkinson’s Disease
____ Liver Disease
____ Asthma/Lung Problems
____ Stroke
____ Kidney Disease
____ Arthritis
____ Glaucoma
____ Blood Clots
Back injury (when and what) _____________________________________________________________
Other_______________________________________________________________________________